ASTH419 Maintain and manage records and reports

Transcription

1 Overview For this unit you need to be able to manage, present and share records and reports. The records and reports relate to your work with or on behalf of service users and for supervision and teamwork. Note- this unit is the imported from Health and Social Care unit HSC434 ASTH419 1

2 Performance criteria You must be able to: P1 you identify legal, organisational and inter-agency policies and protocols for recording and reporting P2 you clarify any uncertainties about recording and reporting with your line manager or professional supervisor P3 you use recording and reporting procedures, including the use of information and communication technology, to produce records and reports that: P3.1 reflect best practice P3.2 are accurate, concise, objective, understandable, legible and accessible P3.3 promote the participation of service users and others in planning, carrying out and reviewing the effectiveness of provision and services in: P3.3.1 meeting their needs P3.3.2 identifying and exposing gaps in resources and services and unmet need P3.3.3 promoting human growth, development and independent living P3.3.4 countering disadvantage, discrimination and social exclusion P3.4 document conflicts, disagreements, unmet needs and any risks associated with these P4 you maintain and update records according to legal, organisational and inter-agency policies and protocols P5 you clearly and accurately record: P5.1 judgements and decisions P5.2 the evidence on which the judgements have been based P5.3 where judgement is based on informed opinion P6 you record other evidence and reports which: P6.1 support your judgements and decisions P6.2 conflict with your judgements and decisions P6.3 clarify events and decisions P7 you check and agree the accuracy of the records and evidence with all concerned in the decision making process, and acquire the appropriate signatures, if required P8 you record and report any disagreements and actions taken to resolve these P9 you identify legal and organisational requirements for confidentiality, access and security of reports and records P10 you balance confidentiality requirements with the need for openness P11 you clarify policy and best practice for method of dissemination ASTH419 2

3 P12 you disseminate records and reports according to legal and organisational requirements and agreements with service users and others P13 you store records and reports: P13.1 in a way that facilitates retrieval and sharing of information P13.2 according to legal and organisational procedures for security P14 you identify: P14.1 legal, organisational and inter-agency requirements for the sharing of information, including the need to maintain privacy, confidentiality and security of information P14.2 the criteria for sharing information including: P how the information will be accessed and shared P the frequency with which information will be shared P14.3 feedback and review mechanisms appropriate to the target audience for the information P15 you share records and reports with others according to legal, organisational and inter-agency requirements and the criteria set P16 you receive, discuss and take action in response to feedback from those who receive your records and/or reports P17 you maintain records of: P17.1 views on progress or the lack of it P17.2 areas of disagreement and conflict P17.3 any actions arising from feedback received ASTH419 3

4 Knowledge and understanding You need to know and understand: K1 your own values, prejudices, ethical dilemmas and conflicts of interest and their implications on your practice K2 respect for, and the promotion of: K2.1 each person as an individual K2.2 independence and quality of life for individuals, whilst protecting them from harm K2.3 dignity and privacy of individuals, families, groups and communities K3 valuing, recognising and respecting the diversity, expertise and experience of individuals, families, groups and communities K4 maintaining the trust and confidence of individuals, families, groups and communities by communicating in an open, accurate and understandable way K5 listening to, respecting, promoting and balancing the views and wishes of individuals, families, groups, communities and other practitioners K6 challenging, through your practice: discrimination, racism, disadvantage and other forms of inequality and injustice K7 local, UK, EU legislation, statutory codes, standards, frameworks and guidance relevant to mental health practice and related fields, including multi-disciplinary and multi-organisational practice on accountability and continuing professional development, data protection and confidentiality of information K8 roles, responsibilities, procedures and timetables for recording, report writing, researching, storing, and disseminating information within the organisation and with other relevant organisations K9 mandatory and discretionary destinations for reports and records including agreements between organisations and service users K10 organisational policies, protocols and practices for the security and confidentiality of information and the sharing of information with other agencies K11 relevant theories on multi-disciplinary and multi-organisational reporting and recording and the differential impact of the status and power of professions and organisations K12 methods of and reasons for mediation and complaints procedures, your responsibility in providing information about them and your role and that of individuals, families, groups and communities in accessing and using them K13 best practice guidance on accessible language, evidence supporting professional judgement, recording differences and conflicts of fact and opinion K14 utilisation of electronic and information technology systems for recording ASTH419 4

5 and report writing K15 methods of: K15.1 recording and report writing for different purposes in care practice and evaluation of their effectiveness K15.2 involving service users in report writing and recording to promote human growth, development and independent living You need to know and understand: In your specific area of practice: K16 reviews of knowledge and practice guidance in relation to records and reports K17 lessons learned from inquiries into serious failure of services and practice K18 guidance from professional and specific policy organisations K19 approaches to learning that will allow you to transfer your knowledge and skills to new and unfamiliar contexts ASTH419 5

6 Developed by AssetSkills Version number 1 Date approved September 2008 Indicative review date Validity Status Originating organisation Original URN Relevant occupations Suite Key words September 2010 Current Imported Skills for Care and Development HSC434 Health, Public Services and Care; Health and Social Care; Managers and Senior Officials; Managers and Proprietors in Hospitality Housing Manage, records, reports, service, supervision, teamwork ASTH419 6